A nurse is collecting data from child who has measles. Which of the following manifestations should the nurse expect to find?
Beefy, red tongue
Paroxysmal cough
Peeling of the hands and feet
Fever
The Correct Answer is D
A) Beefy, red tongue: The beefy, red tongue is typically associated with scarlet fever, a bacterial infection caused by group A Streptococcus. This condition can lead to a red, "strawberry" tongue, often accompanied by a rash. While measles can involve a variety of symptoms, including a red rash, conjunctivitis, and cough, the beefy red tongue is not characteristic of measles. In measles, the more notable symptoms are a high fever, cough, runny nose, and the development of Koplik spots inside the mouth.
B) Paroxysmal cough: Paroxysmal cough, which is a sudden, severe, and uncontrollable cough often followed by a "whooping" sound, is more characteristic of pertussis (whooping cough). While a cough is indeed present with measles, it is generally not paroxysmal. In measles, the cough is more persistent and associated with other typical symptoms such as fever and a characteristic rash. The coughing in measles may also be dry and harsh but does not tend to occur in violent, paroxysmal episodes like those seen in pertussis.
C) Peeling of the hands and feet: Peeling of the skin, particularly of the hands and feet, is more commonly observed in conditions such as scarlet fever, Kawasaki disease, or after a viral infection like hand-foot-and-mouth disease. It is not a classic finding of measles. In measles, the skin rash usually starts as maculopapular spots on the face and spreads down the body. While some skin sloughing can occur after the rash resolves, especially in severe cases, it is not the characteristic sign of measles, and it is not typically seen on the hands and feet.
D) Fever: Fever is one of the earliest and most prominent symptoms of measles. It typically appears about 2-4 days before the characteristic measles rash. The fever in measles can be quite high, often exceeding 104°F (40°C), and is associated with other symptoms such as cough, conjunctivitis, and photophobia. The fever usually persists for several days, and it is one of the critical signs that lead to the diagnosis of measles, particularly when combined with the characteristic rash and other respiratory symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) NG tube: A nasogastric (NG) tube is not typically required for a client with a seizure disorder unless they have specific feeding or aspiration concerns that require tube feeding. During a seizure, the priority is to ensure airway clearance and prevent injury, not necessarily to provide nutrition through an NG tube.
B) Tongue blade: It is a common myth that tongue blades should be used to prevent a client from biting their tongue during a seizure. However, using a tongue blade can be dangerous as it can cause injury to the mouth or teeth, or even cause choking. The nurse should never attempt to place anything in the client's mouth during a seizure.
C) Suction machine: A suction machine is essential for maintaining airway patency during or after a seizure. Clients with seizure disorders may be at risk for aspiration, and the suction machine can be used to clear secretions from the mouth to prevent choking or aspiration pneumonia. This is the most appropriate supply to place at the bedside.
D) Syringe containing lorazepam: While lorazepam (a benzodiazepine) is sometimes used for acute seizure management, it is not a routine item to have immediately at the bedside unless specifically ordered for emergency seizure intervention. The nurse should follow protocol and administer medications as prescribed, but a syringe of lorazepam is not typically pre-placed at the bedside.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"}}
Explanation
Airborne precautions (Anticipated): Tuberculosis is an airborne disease, requiring negative pressure isolation, N95 respirators, and airborne precautions to prevent transmission.
Rifampin (Anticipated): A key first-line TB medication that inhibits bacterial RNA synthesis. It is part of the standard RIPE (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) regimen.
Contact precautions (Contraindicated): TB does not spread via direct contact, so contact precautions (gloves, gowns) are unnecessary unless the client has open wounds with drainage.
Isoniazid (Anticipated): A primary anti-TB drug that inhibits mycolic acid synthesis, crucial for treating active and latent TB infections.
Monthly TB skin test for 1 year (Contraindicated): Once TB is diagnosed, routine Mantoux tests are unnecessary, as they will likely remain positive due to prior exposure.
Pyrazinamide (Anticipated): A bactericidal TB medication used in the intensive phase of treatment to shorten therapy duration.
Ethambutol (Anticipated): Used to prevent drug resistance in TB treatment. Regular eye exams are needed due to the risk of optic neuritis.
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